Prior authorization required

Obtain prior authorization for drugs marked with a PA requirement before dispensing; failure to obtain PA may result in noncoverage.

• PA is defined in the Requirements/Limits field and requires approval before filling the prescription.
• If authorization is not obtained the plan may not cover the drug.

Prior authorization requirements (OVM and oncology mention)

For oncology antineoplastics and supportive care drugs follow the Oncology Value Management (OVM) prior‑authorization process administered by OncoHealth; failure to follow OVM/PA may lead to noncoverage.

• OVM flag in Requirements/Limits indicates OVM prior authorization is required.
• Providers must submit additional clinical information as requested to support OVM/PA determinations.

PA required for PA‑marked drugs

If a formulary entry shows the 'PA' notation in the Requirements/Limits column, initiate the plan's prior authorization process for that specific product prior to fill.

• PA is shown next to products in the formulary; consult the plan's PA process for required submission steps.

PA required for selected anticonvulsants

Prior authorization is required for multiple branded anticonvulsant products (e.g., brivaracetam formulations, EPIDIOLEX, FINTEPLA); obtain PA per the Requirements/Limits before dispensing.

• Brivaracetam solution and tablets list QL and PA (QL(620 ML per 31 days); PA; QL(62 EA per 31 days); PA).
• EPIDIOLEX and other anticonvulsants are marked PA in the formulary lines.

PA required for select epilepsy agents

For listed epilepsy agents such as rufinamide and multiple XCOPRI entries, secure prior authorization and respect any listed quantity limits (QL) before filling.

• Rufinamide suspension and tablets indicate 'Requirements/Limits = PA'.
• XCOPRI therapy packs/tablets show QL entries plus PA (examples: QL(31 EA per 31 days); PA; QL(56 EA per 365 days); PA).

Prior authorization required for select products (examples)

Obtain prior authorization for the listed select products that include PA in the Requirements/Limits column (formulary examples show PA next to items such as DICLOFENAC EPOLAMINE PATCH and others).

• DICLOFENAC EPOLAMINE PATCH is listed with Requirements/Limits = PA.
• Check each product's Requirements/Limits field for PA notation and initiate PA if present.

Prior authorization required for specified drugs (specialty/high‑tier examples)

Many specialty and high‑tier products are designated with PA in the Requirements/Limits field; providers must request prior authorization before prescribing these specialty agents.

• Examples include AIMOVIG injections (QL; PA) and numerous oncology/specialty agents flagged PA.
• Specialty agents often require PA and additional verification (OVM) as shown on their formulary rows.

Prior Authorization required for many specialty agents

Many specialty, oncology, and biologic agents list 'Requirements/Limits = PA' (often with an OVM flag); obtain prior authorization and submit any additional verification requested.

• Multiple agents (e.g., FRUZAQLA, GAVRETO, IBRANCE, IMBRUVICA) show Requirements/Limits = PA; OVM.
• Paired PA/OVM flags indicate plan-managed specialty review processes must be completed prior to coverage.

Prior authorization / step therapy indicated

When a product line shows 'PA' or 'ST' in Requirements/Limits, follow the corresponding prior authorization or step‑therapy processes before dispensing; PA is required where shown and ST must be met for coverage.

• Entries designate PA (prior authorization) and ST (step therapy) in the Requirements/Limits field; comply with these administrative controls.
• Failure to meet PA or ST requirements may result in denial of coverage.

Prior authorization required for select products (GLP‑1 and similar examples)

Prior authorization is required for certain high‑use GLP‑1 and related products (examples include liraglutide, MOUNJARO, OZEMPIC, RYBELSUS) where PA is shown; secure PA and adhere to any listed quantity limits.

• Liraglutide injection shows QL(27 ML per 90 days); PA.
• MOUNJARO, OZEMPIC and related agents display QL values and PA in Requirements/Limits.

Prior authorization for biologic/hematopoietic agents

For listed biologic and hematopoietic agents (e.g., FULPHILA, NEULASTA, ARANESP, EPOGEN), obtain prior authorization and, where indicated, submit OVM documentation; lack of PA may trigger denial.

• FULPHILA and NEULASTA entries include 'Requirements/Limits = PA; OVM'.
• Providers must follow the PA/OVM process for these injectable biologic agents.

Prior authorization required for specified products (examples)

For numerous select products (e.g., ATTRUBY, VYNDAMAX, VECAMYL) that display PA in Requirements/Limits, initiate prior authorization prior to prescribing to avoid coverage denials.

• ATTRUBY lists QL(112 EA per 28 days); PA.
• VECAMYL and VYNDAMAX entries show PA (VYNDAMAX also has QL values).

Prior authorization required for select products (examples)

Certain listed products require prior authorization before coverage (PA flag appears next to the product row); providers must request PA when prescribing these items.

• Examples: PRALUENT (QL; PA), NEXLETOL/NEXLIZET (QL; PA) and others are marked PA in the formulary.
• Obtain PA according to plan instructions for each PA‑flagged product.

Prior authorization and quantity limits

Some dermatologic and specialty agents include both a PA indicator and a quantity limit (QL); obtain PA and ensure prescriptions conform to the listed QL to avoid denial.

• FILSUVEZ shows QL(725.4 GM per 31 days); PA.
• Calcipotriene products list QL(360 GM per 90 days) and PA as applicable.

PA required for select agents

Initiate prior authorization for the select agents listed with 'PA' in their product rows (e.g., JYNARQUE, tolvaptan, XPHOZAH) prior to fill to ensure coverage.

• JYNARQUE therapy pack: QL(56 EA per 28 days); PA.
• Tolvaptan entries show PA with QL values for specific strengths.

Prior authorization required for specific drugs (MOVANTIK, GATTEX examples)

Prior authorization is required for specific listed drugs such as MOVANTIK, GATTEX, MYALEPT, VOWST, and XIFAXAN as indicated by 'PA' in Requirements/Limits; submit PA requests for these products.

• GATTEX and MYALEPT are shown with Requirements/Limits = PA.
• VOWST and XIFAXAN include QL entries and PA where noted.

Step therapy requirement (general)

Follow step therapy where indicated: some drugs require trial of preferred therapies first (ST flag); if ST applies, coverage for the listed product depends on meeting the step requirement.

• Step Therapy (ST) is defined in the Requirements/Limits field and requires trying specified drugs first.
• If a step is unmet, coverage for the alternative drug may be denied until criteria are satisfied.

Step therapy (general definition/use)

Step therapy may require trying a specified drug first before coverage of alternatives; check the formulary 'Requirements/Limits' field for the ST flag and follow plan procedures.

• The formulary introduction explains ST meaning and directs providers to the Requirements/Limits column to identify ST.
• EXXUA shows Requirements/Limits = QL(...); ST indicating step controls on that product.

Step therapy flag — oxcarbazepine ER

Oxcarbazepine extended‑release tablets are labeled 'ST' in Requirements/Limits; follow the step therapy requirement for the ER formulation before coverage.

• Oxcarbazepine ER tablet (300mg, 600mg) lists Requirements/Limits = ST.
• EXXUA titration pack also shows ST among its Requirements/Limits.

Step therapy controls (oxcarbazepine ER, EXXUA)

Products labeled 'ST' (for example oxcarbazepine ER and EXXUA) are subject to step therapy controls; ensure step requirements are documented when requesting coverage.

• EXXUA: Requirements/Limits = QL(32 EA per 14 days); ST.
• Oxcarbazepine ER: Requirements/Limits = ST.

Step therapy flags present (general)

Step therapy flags appear on multiple agents; check each product's Requirements/Limits and follow plan‑specified step protocols when prescribing.

• Several antipsychotics and other classes show ST in Requirements/Limits (see LAI and other entries).
• If ST applies, documentation of prior trials may be required for approval.

Step or specialty program flags (RYTARY example)

RYTARY's formulary row includes 'Requirements/Limits = QL(...); ST' indicating a quantity limit plus a step‑therapy or specialty program flag — comply with both when requesting coverage.

• RYTARY lists QL(360 EA per 30 days); ST.
• Providers should document trial history and prescribe within the QL to avoid denials.

Step therapy present for specific agents (LAI and oral antipsychotics)

Step therapy is specified for several long‑acting injectables and oral agents (examples include ARISTADA, INVEGA SUSTENNA/TRINZA, PERSERIS); obtain necessary documentation that step requirements were met before fill.

• ARISTADA and INVEGA SUSTENNA/TRINZA list Requirements/Limits = ST.
• PERSERIS is also shown with ST in Requirements/Limits.

Step therapy noted for select insulins (APIDRA example)

Some insulin products (e.g., APIDRA SOLOSTAR) include an 'ST' indicator; follow step‑therapy requirements per the formulary when prescribing these insulin products.

• APIDRA lists Requirements/Limits = ST.
• Check the formulary line for ST and document prior therapy trials where required.

Step therapy not specified in this section

No explicit step‑therapy algorithms are provided in this excerpt; where ST is shown on a product line, check plan criteria or contact the plan for drug‑specific step rules.

• The document shows ST flags but does not list full step algorithms in these chunks.
• Contact plan resources or the online PA/ST documentation for specific step requirements.

Step therapy present (JARDIANCE example)

JARDIANCE is shown with 'ST' in Requirements/Limits; ensure step‑therapy criteria are met before coverage is requested.

• JARDIANCE entry: Requirements/Limits = QL(90 EA per 90 days); ST.
• Document prior trials per plan guidance to support coverage.

Exception request documentation requirements

When requesting an exception to the formulary or to waive a PA/QL/ST requirement, the prescriber must provide a supporting statement explaining the medical rationale; the plan generally decides within 72 hours or 24 hours for expedited requests.

• Prescriber must explain why formulary alternatives or applying the restriction would not be as effective or would cause harm.
• Standard exception decisions: within 72 hours; expedited: within 24 hours.

Required documentation for B/D determination and OVM

For B/D coverage determinations and Oncology Value Management cases, submit the additional clinical and setting information requested by the plan to support the B/D determination or OVM prior authorization.

• B/D notation means coverage may depend on whether the drug is covered under Medicare Part B or D and may require submission of use/setting details.
• OVM entries require OncoHealth submission of additional clinical information.

Quantity limits (provider action notice)

Observe and document quantity limits (QL) shown for many products; submit days‑supply and quantity consistent with the listed QL to avoid claim denials.

• Examples include QL(372 EA per 31 days) for oxycodone tablets and QL(136 ML per 10 days) for DIFICID suspension.
• When prescribing, ensure the dispense quantity and days' supply align with the QL.

Quantity limit documentation (specific examples)

Document exact quantity limits shown for specific products when submitting claims or PA requests (e.g., DIFICID suspension QL(136 ML per 10 days); DIFICID tablet QL(20 EA per 10 days)).

• Provide prescription quantity and days' supply that match QL entries to reduce risk of denial.
• Include QL rationale in PA/exception documentation when relevant.

Formulary annotations — tier and flags

Formulary lines include operational flags (PA, QL, ST, OVM, NDS); follow the Requirements/Limits field on each product row when submitting claims or authorization requests.

• Requirements/Limits is the authoritative field for utilization controls per the formulary introduction.
• Check each product's line for PA, QL, ST, OVM before dispensing.

Follow Requirements/Limits field

Use the 'Requirements/Limits' field on the formulary as the operative guide: it indicates QL, PA, OVM, ST or other administrative flags that must be followed per plan instructions.

• The introduction explains the meaning of QL, PA, ST, OVM and NDS used in the Requirements/Limits column.
• Follow plan processes tied to the flags shown when filing claims or PA requests.

Quantity limit documentation (RUBRACA example)

When products list explicit quantity limits (QL) and PA together (e.g., RUBRACA QL(124 EA per 31 days); PA), ensure PA submissions and claims reflect the prescribed quantity and days' supply consistent with the QL.

• RUBRACA lists QL(124 EA per 31 days); PA.
• VENCLEXTA STARTING PACK lists QL(84 EA per 365 days); PA.

Quantity limits documented (examples)

Several products include QL values (e.g., LYBALVI QL(30 EA per 30 days); paliperidone ER QL(180 EA per 90 days)); ensure dispensing and authorization requests conform to these limits.

• OPIPZA film entries include QL values and PA notation.
• Paliperidone ER has QL(180 EA per 90 days) listed.

Adhere to listed quantity limits

Adhere to listed quantity limits (QL) when prescribing and documenting days' supply (e.g., PREZISTA QL(1440 EA per 90 days); oseltamivir QL(168 EA per 180 days)); mismatched quantities may lead to denial.

• Provide prescription quantity and days' supply consistent with the QL to avoid coverage issues.
• Include justification in PA or exception requests if exceeding a QL is clinically necessary.

PA required for select agents (hematologic biologics)

Prior authorization is required for selected hematologic/biologic injectable agents (e.g., ARANESP ALBUMIN FREE, EPOGEN, PROCRIT, NEULASTA, FULPHILA); obtain PA and submit required clinical documentation.

• FULPHILA and NEULASTA include Requirements/Limits = PA; OVM.
• ARANESP, EPOGEN, PROCRIT are listed with PA in the Requirements/Limits field.

Quantity‑limit compliance

Comply with quantity‑limit enforcement: claims must conform to listed QLs (e.g., QL(90 EA per 90 days), QL(180 EA per 90 days)); submit PA or exception requests if clinical need exceeds the QL.

• Document days' supply and quantity consistent with the QL at claim/PA submission.
• Use the exception process with prescriber supporting statement if exceeding the QL is medically necessary.

PA requirement — operational reminder

This operational reminder reiterates that when the formulary shows 'PA' the prescriber must obtain prior authorization before filling the product to secure coverage.

• PA flag on a product row indicates prior authorization is required.
• Claims submitted without required PA may be denied.

Documentation of QL and PA

Document QL and PA indicators on the prescription and in any authorization requests; include quantity, days' supply, and supporting clinical information that match the formulary's QL/PA entries.

• Examples of QL values: '360 GM per 90 days', '725.4 GM per 31 days'.
• Show PA status on authorization forms and include matching quantity details.

Quantity limits documented (JYNARQUE, tolvaptan examples)

Certain products list specific QL values (e.g., JYNARQUE QL(56 EA per 28 days); tolvaptan entries) and also require PA; obtain PA and ensure dispense quantity matches the QL.

• JYNARQUE: QL(56 EA per 28 days); PA.
• Tolvaptan entries include QL values and PA (generic and brand distinctions noted).

Prior authorization — denial risk if not obtained

Many products are designated with PA and may have accompanying limits (QL or OVM); failure to obtain PA or to meet limits increases the risk of denial — submit PA and document compliance with limits.

• The formulary introduction states missing PA may result in noncoverage.
• Utilization management flags (PA, ST, QL) may trigger denials if unmet.

Prior authorization and Oncology Value Management — denial risk

Failure to obtain required PA or to follow Oncology Value Management (OVM) for antineoplastics/supportive care may result in noncoverage; providers must submit OVM/PA documentation through the OncoHealth process.

• OVM is defined as the PA program for oncology drugs administered by OncoHealth.
• OVM/PA entries on oncology agents indicate additional verification steps required.

Prior authorization indicated — denial risk

Entries flagged 'PA' (such as lidocaine patch, ARIKAYCE, VOQUEZNA packs) indicate prior authorization is required; not securing PA may cause the claim to be denied.

• Lidocaine patch and topical entries show QL and PA notations in Requirements/Limits.
• ARIKAYCE and VOQUEZNA therapy packs are listed with PA flags.

PA requirements for selected anticonvulsants — denial risk

Prior authorization is listed for multiple anticonvulsants (e.g., brivaracetam, EPIDIOLEX, FINTEPLA, FYCOMPA); incomplete PA submissions risk denial of coverage.

• Brivaracetam entries show QL and PA (QL(620 ML per 31 days); PA).
• EPIDIOLEX and FINTEPLA entries are marked PA in the formulary.

XCOPRI PA and QL — denial risk

XCOPRI therapy packs and tablets include both PA and quantity limits (QL); requests that do not meet PA or QL requirements may be denied.

• XCOPRI therapy packs list QL examples (e.g., QL(168 EA per 84 days); QL(56 EA per 365 days)) plus PA.
• XCOPRI tablets include QL(31 EA per 31 days); PA.

Prior Authorization indicated — denial risk

Drugs marked 'PA' (e.g., rufinamide, multiple XCOPRI entries) require prior authorization; lack of PA may result in coverage denial.

• Rufinamide suspension and tablets are marked 'PA' in Requirements/Limits.
• Formulary introduction states missing PA may lead to noncoverage.

Step therapy indicated — denial risk if unmet

Products annotated with 'ST' such as oxcarbazepine ER and EXXUA may be denied if step therapy requirements are not satisfied; document prior therapy trials when submitting PA or claims.

• EXXUA: Requirements/Limits = QL(...); ST.
• Oxcarbazepine ER explicitly lists ST in Requirements/Limits.

Prior authorization required for listed products — denial risk

Some listed products require prior authorization as noted in the Requirements/Limits field; claims submitted without required PA are at risk of denial.

• The formulary's Requirements/Limits field identifies PA requirements for individual drugs.
• Providers should confirm PA status prior to dispensing to avoid claim denials.

PA & OVM requirement common — denial risk

Claims for many specialty oncology and targeted agents listing 'PA; OVM' may be denied if PA/OVM are not completed; ensure OVM submissions are routed through OncoHealth as required.

• Numerous oncology/targeted therapies show 'PA; OVM' in Requirements/Limits (examples throughout chunks 108–117).
• OVM submissions require additional clinical information via the plan's oncology management process.

Utilization management may trigger denial

Utilization management flags (PA, ST, QL) applied to drugs may trigger coverage denial if the requirements are not met; verify and document compliance before submitting claims.

• The formulary shows PA, ST and QL codes that indicate utilization controls.
• Noncompliance with these controls can result in denial.

PA required for Humulin R U‑500

Humulin R U-500 (Kwikpen and other concentrated forms) requires prior authorization; absence of PA may result in denial of coverage.

• HUMULIN R U-500 and its Kwikpen formulation are identified with PA in the formulary.
• Obtain PA before dispensing concentrated insulin formulations.

PA and QL indicated for select injectables

Some hematologic biologic injectables (e.g., ARANESP, EPOGEN, PROCRIT, NEULASTA, FULPHILA) require prior authorization and may also have quantity limits; secure PA and document quantity/days' supply.

• NEULASTA and FULPHILA entries list Requirements/Limits = PA; OVM.
• Provide required clinical documentation for PA to avoid denial.

Prior authorization required for select products — denial risk

Some listed products (e.g., ATTRUBY, JYNARQUE, tolvaptan) show 'PA' in Requirements/Limits; obtain prior authorization to prevent denials.

• ATTRUBY: QL(112 EA per 28 days); PA.
• JYNARQUE and tolvaptan entries list PA alongside QL values.

PA for specialty/high‑tier agents

For listed specialty/high‑tier agents such as VECAMYL and VYNDAMAX that carry a PA flag, secure prior authorization before treatment initiation to ensure coverage.

• VECAMYL: Requirements/Limits = PA.
• VYNDAMAX: Requirements/Limits = QL(31 EA per 31 days); PA.

Prior authorization indicated for select drugs

Coverage for numerous listed products (e.g., NEXLETOL, NEXLIZET, PRALUENT, KERENDIA, VERQUVO) may be subject to prior authorization; confirm PA requirements and submit appropriate documentation.

• NEXLETOL/NEXLIZET entries show QL and PA.
• PRALUENT lists QL(2 ML per 28 days); PA.

Prior authorization/Quantity limit denials

Certain products apply both PA and QL controls; failure to obtain PA or to adhere to QL may result in denial — ensure PA approvals and dispense within QL limits.

• Examples include dermatologic agents and specialty injectables with both PA and QL flags.
• Document PA approval and match dispense quantity/days' supply to QL.

Prior authorization indicated for select products

Some products require prior authorization (PA) — for example JYNARQUE and tolvaptan entries list PA in Requirements/Limits; request PA before dispensing.

• JYNARQUE therapy pack: QL(56 EA per 28 days); PA.
• Tolvaptan entries include PA and QL values for specific strengths.

Prior authorization and limits noted on select drugs

Coverage for listed specialty drugs such as MOVANTIK, GATTEX, MYALEPT is subject to prior authorization per the Requirements/Limits field; obtain PA and provide requested clinical details.

• GATTEX and MYALEPT show Requirements/Limits = PA.
• MOVANTIK and others are identified with PA in the formulary listings.